A charge nurse is evaluating a newly licensed nurse caring for a client who is using a PCA device.
Which of the following actions by the nurse requires intervention by the charge nurse?
The nurse asks the client to demonstrate dose delivery.
The nurse administers a PCA dose for the client.
The nurse reassures the client that the PCA device will not cause an overdose.
The nurse monitors the client for oversedation.
The Correct Answer is B
Choice A rationale:
Asking the client to demonstrate dose delivery can be part of patient education and helps ensure that the client understands how to use the PCA device. This action does not require intervention.
Choice B rationale:
The nurse administering a PCA dose for the client requires intervention. PCA stands for “Patient-Controlled Analgesia,” meaning that only the patient should administer doses to themselves. This prevents overdosing and ensures that pain medication is administered according to the patient’s needs.
Choice C rationale:
Reassuring the client that the PCA device will not cause an overdose is appropriate because PCA devices are designed with safety measures to prevent overdosing.
Choice D rationale:
Monitoring for oversedation is an important part of care for a client using a PCA device. This action does not require intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.2"]
Explanation
To calculate the dose of somatropin to be administered per dose, we first need to convert the child's weight from pounds to kilograms. We can do this using the following conversion factor:
1 kg = 2.2 lbs
Therefore, the child's weight in kilograms is:
weight_kg = 66 lbs / 2.2 lbs/kg = 30 kg
Next, we can calculate the total dose of somatropin to be administered per week using the following formula:
total_dose = weight_kg * 0.24 mg/kg/week
This gives us a total dose of:
total_dose = 30 kg * 0.24 mg/kg/week = 7.2 mg/week
Finally, we can calculate the dose of somatropin to be administered per dose by dividing the total dose by the number of daily doses:
dose_per_dose = total_dose / 6 doses/day = 1.2 mg/dose
Therefore, the nurse should administer 1.2 mg of somatropin per dose.
Answer: 1.2 mg of somatropin per dose.
Correct Answer is C
Explanation
Choice A rationale:
Hanging the antibiotic medication bag above the level of the primary infusion is an important step in administering an antibiotic via intermittent IV bolus. However, it is not the first step. The medication bag is usually hung higher to allow the antibiotic to infuse by gravity once it’s connected.
Choice B rationale:
Wiping the connection port of the primary IV tubing with an antiseptic swab is a crucial step in preventing infection. However, this is typically done just before connecting the secondary line, not as the first step.
Choice C rationale:
Checking the IV site for signs of infiltration is indeed the first step. It’s important to ensure that the IV catheter is still properly placed in the vein and that there are no signs of infection or infiltration, which could cause complications.
Choice D rationale:
Connecting the tubing of the medication bag to the primary tubing is done after cleaning the port and before hanging the bag. It’s not the first step.
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